Smart Dosing, Better Outcomes: An Electronic Medical Record Intervention for Cancer Pain in the Emergency Department

Objectives We hypothesized that an electronic medical record (EMR)-based best practice advisory (BPA), offering individualized opioid dosing for cancer patients with high opioid tolerance, would improve pain control and reduce hospital admissions in the emergency department (ED). Methods We conducted a retrospective cohort study from May 2020 to May 2024 across 2 academic EDs affiliated with a National Comprehensive Cancer Network cancer center. Adult patients with active cancer, a morphine equivalent daily dose (MEDD) ≥100, and an ED opioid order were eligible. The BPA calculated MEDD-based opioid dosing recommendations and provided safety measures. Patients were categorized as BPA+ (recommendation followed) or BPA− (recommendation ignored). The primary outcome was hospital admission. Secondary outcomes included ED length of stay and change in pain scores. Results Among 1193 patient encounters, 719 (60.3%) received BPA-directed therapy. BPA+ was associated with a lower odds ratio (OR) of admission compared to BPA− (OR, 0.67; 95% CI, 0.49-0.80). The BPA was associated with decreased admission rates in patients with an Eastern Cooperative Oncology Group performance status of 4 (54% vs 80% admitted) and stage 4 cancer (57% vs 68% admitted). BPA+ was also associated with greater median pain improvement (−2 vs −1) and shorter ED stays (8.2 vs 8.9 hours). Among patients receiving multiple opioid doses, greater BPA adherence was associated with sustained pain reduction, while BPA nonadherence showed diminished response. Conclusion An EMR-integrated BPA for opioid-tolerant cancer patients was associated with improved ED pain management and reduced admissions. These findings support broader use of EMR-based tools to promote guideline-concordant, personalized care for cancer-related pain.